Provider Demographics
NPI:1679005599
Name:ROBERTSON, DAVID (RN)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10013 JOES BAYOU RD
Mailing Address - Street 2:
Mailing Address - City:BAY ST LOUIS
Mailing Address - State:MS
Mailing Address - Zip Code:39520-1702
Mailing Address - Country:US
Mailing Address - Phone:601-422-9626
Mailing Address - Fax:
Practice Address - Street 1:10013 JOES BAYOU RD
Practice Address - Street 2:
Practice Address - City:BAY ST LOUIS
Practice Address - State:MS
Practice Address - Zip Code:39520-1702
Practice Address - Country:US
Practice Address - Phone:601-422-9626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR855938163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse